Distinguishing Clinical From Statistical Significances in Contemporary Comparative Effectiveness Research.

OBJECTIVE: To determine the prevalence of clinical significance reporting in contemporary comparative effectiveness research (CER). BACKGROUND: In CER, a statistically significant difference between study groups may or may not be clinically significant. Misinterpreting statistically significant results could lead to inappropriate recommendations that increase health care costs and treatment toxicity. METHODS: CER studies from 2022 issues of the Annals of Surgery , Journal of the American Medical Association , Journal of Clinical Oncology , Journal of Surgical Research , and Journal of the American College of Surgeons were systematically reviewed by 2 different investigators. The primary outcome of interest was whether the authors specified what they considered to be a clinically significant difference in the "Methods." RESULTS: Of 307 reviewed studies, 162 were clinical trials and 145 were observational studies. Authors specified what they considered to be a clinically significant difference in 26 studies (8.5%). Clinical significance was defined using clinically validated standards in 25 studies and subjectively in 1 study. Seven studies (2.3%) recommended a change in clinical decision-making, all with primary outcomes achieving statistical significance. Five (71.4%) of these studies did not have clinical significance defined in their methods. In randomized controlled trials with statistically significant results, sample size was inversely correlated with effect size ( r = -0.30, P = 0.038). CONCLUSIONS: In contemporary CER, most authors do not specify what they consider to be a clinically significant difference in study outcome. Most studies recommending a change in clinical decision-making did so based on statistical significance alone, and clinical significance was usually defined with clinically validated standards.

Health care spending and quality in year 1 of the alternative quality contract.

BACKGROUND: In 2009, Blue Cross Blue Shield of Massachusetts (BCBS) implemented a global payment system called the Alternative Quality Contract (AQC). Provider groups in the AQC system assume accountability for spending, similar to accountable care organizations that bear financial risk. Moreover, groups are eligible to receive bonuses for quality. METHODS: Seven provider organizations began 5-year contracts as part of the AQC system in 2009. We analyzed 2006-2009 claims for 380,142 enrollees whose primary care physicians (PCPs) were in the AQC system (intervention group) and for 1,351,446 enrollees whose PCPs were not in the system (control group). We used a propensity-weighted difference-in-differences approach, adjusting for age, sex, health status, and secular trends to isolate the treatment effect of the AQC in comparisons of spending and quality between the intervention group and the control group. RESULTS: Average spending increased for enrollees in both the intervention and control groups in 2009, but the increase was smaller for enrollees in the intervention group--$15.51 (1.9%) less per quarter (P=0.007). Savings derived largely from shifts in outpatient care toward facilities with lower fees; from lower expenditures for procedures, imaging, and testing; and from a reduction in spending for enrollees with the highest expected spending. The AQC system was associated with an improvement in performance on measures of the quality of the management of chronic conditions in adults (P<0.001) and of pediatric care (P=0.001), but not of adult preventive care. All AQC groups met 2009 budget targets and earned surpluses. Total BCBS payments to AQC groups, including bonuses for quality, are likely to have exceeded the estimated savings in year 1. CONCLUSIONS: The AQC system was associated with a modest slowing of spending growth and improved quality of care in 2009. Savings were achieved through changes in referral patterns rather than through changes in utilization. The long-term effect of the AQC system on spending growth depends on future budget targets and providers' ability to further improve efficiencies in practice. (Funded by the Commonwealth Fund and others.).

The business case for quality: estimating lives saved and harms avoided in a value-based purchasing model.

Ever-increasing concern about the cost and burden of quality measurement and reporting raises the question: How much do patients benefit from provider arrangements that incentivize performance improvements? We used national performance data to estimate the benefits in terms of lives saved and harms avoided if US health plans improved performance on 2 widely used quality measures: blood pressure control and colorectal cancer screening. We modeled potential results both in California Marketplace plans, where a value-based purchasing initiative incentivizes improvement, and for the US population across 4 market segments (Medicare, Medicaid, Marketplace, commercial). The results indicate that if the lower-performing health plans improve to 66th percentile benchmark scores, it would decrease annual hypertension and colorectal cancer deaths by approximately 7% and 2%, respectively. These analyses highlight the value of assessing performance accountability initiatives for their potential lives saved and harms avoided, as well as their costs and efforts.

Measuring chronic care delivery: patient experiences and clinical performance.

OBJECTIVE: To assess the relationship between clinical care metrics and patient experiences of care among patients with chronic disease. DESIGN: Cross-sectional survey and clinical performance data. SETTING: Eighty-nine medical groups across California caring for patients with chronic disease. PARTICIPANTS: Using patient surveys, we identified 51 129 patients with a chronic disease. MAIN OUTCOME MEASURES: Using patient surveys, we produced five composite measures of patient experiences of care and self-management support (scale 0-100). Using Health Plan Employer Data and Information Set data, we analyzed care for asthma, diabetes and cardiovascular disease, producing one composite summarizing clinical processes of care and one composite summarizing outcomes of care. We calculated adjusted Spearman's correlation coefficients to assess the relationship between patient experiences of care, clinical processes and clinical outcomes. RESULTS: Clinical performance was higher for process measures compared with outcomes measures, ranging from 91% for appropriate asthma medication use to 59% for controlling low-density lipoprotein cholesterol in the presence of diabetes. Performance on patient experiences of care measures was the highest for the quality of clinical interactions (88.5) and the lowest for delivery of self-management support (68.8). Three of the 10 patient experience-clinical performance composite correlations were statistically significant. These three correlations involved composites summarizing integration of care and quality of clinical interactions, and ranged from a low of 0.30 to a high of 0.39. CONCLUSIONS: Chronic care delivery is variable across diseases and domains of care. Improving care integration processes and communication between health-care providers and their patients may lead to improved clinical outcomes.

Reliability of medical group and physician performance measurement in the primary care setting.

BACKGROUND: Performance reporting is increasingly focused on physician practice sites and individual physicians. OBJECTIVE: To assess the reliability of performance measurement for practice sites and individual physicians. RESEARCH DESIGN: We used data collected across multiple payers as part of a statewide measurement collaborative to evaluate the observed measure reliability and sample size requirements to achieve acceptable reliability of 4 Health Care Effectiveness Data and Information Set measures of preventive care and 10 Health Care Effectiveness Data and Information Set measures of chronic care across 334 practice sites. We conducted a parallel set of physician-level analyses using data across 118 primary physicians practicing within a large multispecialty group. MEASURES: Observed reliabilities and estimated sample size requirements to achieve reliability ≥0.70. RESULTS: At the practice site level, sample sizes required to achieve a reliability of 0.70 were less than 200 patients per site for all 4 measures of preventive care, all 4 process measures of diabetes care, and 2 outcomes measures of diabetes care. Larger samples were required to achieve reliability for cholesterol screening in the presence of cardiovascular disease (n = 249) and use of appropriate asthma medications (n = 351). At the physician level, less than 200 patients were required for all 4 measures of preventive care, but for many chronic care measures the samples of patients available per physician were not sufficient to achieve a reliability of 0.70. CONCLUSION: In a multipayer collaborative, sample sizes were adequate to reliably assess clinical process and outcome measures at the practice site level. For individual physicians, sample sizes proved adequate to reliably measure preventive care, but may not be feasible for chronic care assessment.

Use of prescription drug samples and patient assistance programs, and the role of doctor-patient communication.

BACKGROUND: Cost-related underuse of medications is common among older adults, who seldom discuss medication costs with their physicians. Some older adults may use free drug samples or industry-sponsored patient assistance programs (PAP) in hopes of lowering out-of-pocket costs, although the long-term effect of these programs on drug spending is unclear. OBJECTIVE: To examine older adults' use of industry-sponsored strategies to reduce out-of-pocket drug costs and the association between doctor-patient communication and use of these programs. DESIGN: Cross-sectional analysis of a 2006 nationally representative survey of Medicare beneficiaries. PARTICIPANTS: 14,322 community-dwelling Medicare beneficiaries age ≥65. MAIN MEASURES: We conducted bivariate and multivariate analyses of the association between receipt of free samples and participation in PAPs with sociodemographic characteristics, health status, access to care, drug coverage, medication cost burden, and doctor-patient communication. KEY RESULTS: 51.4% of seniors reported receiving at least one free sample over the last 12 months and 29.2% reported receiving free samples more than once. In contrast, only 1.3% of seniors reported participating in an industry-sponsored PAP. Higher income respondents were more likely to report free sample receipt than low-income respondents (50.8% vs. 43.8%, p < 0.001) and less likely to report participating in a PAP (0.42% vs. 2.2%, p < 0.001). In multivariate analyses, those who reported talking to their doctor about the cost of their medications had more than twice the odds of receiving samples as those who did not (OR 2.17, 95% CI 1.95-2.42). CONCLUSIONS: In 2006, over half of seniors in Medicare received free samples, but only 1.3% reported receiving any medications from a patient assistance program. Doctor-patient communication is strongly associated with use of these programs, which has important implications for clinical care regardless of whether these programs are viewed as drivers of prescription costs or a remedy for them.

Promoting patient-centered care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience.

OBJECTIVE: To investigate organizational facilitators and barriers to patient-centered care in US health care institutions renowned for improving the patient care experience. DESIGN: A qualitative study involving interviews of senior staff and patient representatives. Semi-structured interviews focused on organizational processes, senior leadership, work environment, measurement and feedback mechanisms, patient engagement and information technology and access. SETTING: Eight health care organizations across the USA with a reputation for successfully promoting patient-centered care. PARTICIPANTS: Forty individuals, including chief executives, quality directors, chief medical officers, administrative directors and patient committee representatives. RESULTS: Interviewees reported that several organizational attributes and processes are key facilitators for making care more patient-centered: (i) strong, committed senior leadership, (ii) clear communication of strategic vision, (iii) active engagement of patient and families throughout the institution, (iv) sustained focus on staff satisfaction, (v) active measurement and feedback reporting of patient experiences, (vi) adequate resourcing of care delivery redesign, (vii) staff capacity building, (viii) accountability and incentives and (ix) a culture strongly supportive of change and learning. Interviewees reported that changing the organizational culture from a 'provider-focus' to a 'patient-focus' and the length of time it took to transition toward such a focus were the principal barriers against transforming delivery for patient-centered care. CONCLUSIONS: Organizations that have succeeded in fostering patient-centered care have gone beyond mainstream frameworks for quality improvement based on clinical measurement and audit and have adopted a strategic organizational approach to patient focus.

Cultural competency training and performance reports to improve diabetes care for black patients: a cluster randomized, controlled trial.

BACKGROUND: Increasing clinician awareness of racial disparities and improving communication may enhance diabetes care among black patients. OBJECTIVE: To evaluate the effect of cultural competency training and performance feedback for primary care clinicians on diabetes care for black patients. DESIGN: Cluster randomized, controlled trial conducted between June 2007 and May 2008. (ClinicalTrials.gov registration number: NCT00436176) SETTING: 8 ambulatory health centers in eastern Massachusetts. PARTICIPANTS: 124 primary care clinicians caring for 2699 (36%) black and 4858 (64%) white diabetic patients. INTERVENTION: INTERVENTION clinicians received cultural competency training and monthly race-stratified performance reports that highlighted racial differences in control of hemoglobin A(1c) (HbA(1c)) and low-density lipoprotein (LDL) cholesterol levels and blood pressure. MEASUREMENTS: Clinician awareness of racial differences in diabetes care and rates of achieving clinical control targets among black patients at 12 months. RESULTS: White and black patients differed significantly in baseline rates of achieving an HbA(1c) level less than 7% (46% vs. 40%), an LDL cholesterol level less than 2.59 mmol/L (<100 mg/dL) (55% vs. 43%), and blood pressure less than 130/80 mm Hg (32% vs. 24%) (all P < 0.050). At study completion, intervention clinicians were significantly more likely than control clinicians to acknowledge the presence of racial disparities in the 8 health centers as a whole (82% vs. 59%; P = 0.003), within their local health center (70% vs. 51%; P = 0.020), and among their own patients (63% vs. 43%; P = 0.037). Black patients of clinicians in the intervention and control groups did not differ at 12 months in rates of controlling HbA(1c) level (48% vs. 45%; P = 0.24), LDL cholesterol level (48% vs. 49%; P = 0.40), or blood pressure (23% vs. 25%; P = 0.47). LIMITATION: 11% of primary care teams did not attend cultural competency training sessions. CONCLUSION: The combination of cultural competency training and race-stratified performance reports increased clinician awareness of racial disparities in diabetes care but did not improve clinical outcomes among black patients.

Prescription coverage, use and spending before and after Part D implementation: a national longitudinal panel study.

BACKGROUND: In January 2006, 43 million Medicare beneficiaries became eligible for subsidized prescription coverage (Part D) through Medicare. To date, no longitudinal study has afforded information on beneficiaries' prescription coverage transitions and corresponding changes in prescription use and spending. OBJECTIVE: To evaluate changes in Medicare beneficiaries' prescription coverage, use and spending before and after Part D implementation, including comparison of those who enrolled in Part D with those who did not. DESIGN, SETTING AND PARTICIPANTS: Longitudinal observational study of non-institutionalized Medicare beneficiaries aged 65 and older (n = 9,573) employing administrative data from the Centers for Medicare and Medicaid Services (CMS) and survey-based data from beneficiaries (2003, 2006). Sampling drew from a 1% national probability sample (2003), oversampling low-income beneficiaries including those dually-enrolled in Medicare and Medicaid. MEASUREMENTS & MAIN RESULTS: Number and type of prescriptions, monthly out-of-pocket prescription spending, and cost-related non-adherence to prescription regimens. Most respondents who lacked prescription coverage in 2003 had acquired it by 2006 (82.6%)-primarily through Part D (63.1%). Part D enrollees who previously lacked coverage or had Medigap coverage appear particularly advantaged by Part D, as evidenced by significantly increased prescription use, lower out-of-pocket spending and lower non-adherence. Those with employer-based coverage experienced significantly increased spending. Among those still lacking coverage in 2006, high rates of cost-related non-adherence (31.8%) were reported by the low-income, chronically ill subgroup. CONCLUSIONS: In its first year, Part D coverage appears to have moderated prescription spending and cost-related burden for those who previously had meager benefits or none. Increased spending among those with employer-based coverage may reflect a narrowing of those benefits over this period. Evidence of foregone care among low-income, chronically ill seniors who still lack prescription coverage highlights the importance of targeted outreach to this group for Part D's low-income subsidy program.

Associations between structural capabilities of primary care practices and performance on selected quality measures.

BACKGROUND: Recent proposals to reform primary care have encouraged physician practices to adopt such structural capabilities as performance feedback and electronic health records. Whether practices with these capabilities have higher performance on measures of primary care quality is unknown. OBJECTIVE: To measure associations between structural capabilities of primary care practices and performance on commonly used quality measures. DESIGN: Cross-sectional analysis. SETTING: Massachusetts. PARTICIPANTS: 412 primary care practices. MEASUREMENTS: During 2007, 1 physician from each participating primary care practice (median size, 4 physicians) was surveyed about structural capabilities of the practice (responses representing 308 practices were obtained). Data on practice structural capabilities were linked to multipayer performance data on 13 Healthcare Effectiveness Data and Information Set (HEDIS) process measures in 4 clinical areas: screening, diabetes, depression, and overuse. RESULTS: Frequently used multifunctional electronic health records were associated with higher performance on 5 HEDIS measures (3 in screening and 2 in diabetes), with statistically significant differences in performance ranging from 3.1 to 7.6 percentage points. Frequent meetings to discuss quality were associated with higher performance on 3 measures of diabetes care (differences ranging from 2.3 to 3.1 percentage points). Physician awareness of patient experience ratings was associated with higher performance on screening for breast cancer and cervical cancer (1.9 and 2.2 percentage points, respectively). No other structural capabilities were associated with performance on more than 1 measure. No capabilities were associated with performance on depression care or overuse. LIMITATION: Structural capabilities of primary care practices were assessed by physician survey. CONCLUSION: Among the investigated structural capabilities of primary care practices, electronic health records were associated with higher performance across multiple HEDIS measures. Overall, the modest magnitude and limited number of associations between structural capabilities and clinical performance suggest the importance of continuing to measure the processes and outcomes of care for patients. PRIMARY FUNDING SOURCE: The Commonwealth Fund.

Attributing sources of variation in patients' experiences of ambulatory care.

BACKGROUND: Public reporting and pay-for-performance programs increasingly rely on patient experience data to evaluate individual physicians and guide quality improvement efforts. The extent to which performance variation is attributable to physicians versus other system-level units, however, remains unclear. METHODS: Using ambulatory care experience survey data from 61,839 patients of 1729 primary care physicians in California (response rate = 39.1%), this study assesses the proportion of explainable performance variation attributable to various organizational units in composite measures of physician-patient interaction, organizational features of care, and global assessments of care. For each measure, multilevel regression models that controlled for respondent characteristics and used random effects to account for the clustering of patients within physicians, physicians within care sites, care sites within medical groups, and medical groups within primary care service areas, estimated the proportion of explainable performance variation attributable to each system-level unit. RESULTS: System-level factors explained between 27.9% to 47.7% of variation, with the highest proportion explained for the access to care composite and the lowest explained for the quality of chronic care composite. Physicians accounted for the largest proportion of explainable variance for all measures (range: 35.1%-49.0%). Care sites and primary care service areas explained substantial proportions of variance (>20% each) for the access to care and care coordination measures. Medical groups explained the largest proportions of variation (>20%) for global assessments of care. CONCLUSIONS: Individual physicians and their care sites are the most important foci for patient experience improvement efforts. Because markets contribute substantially to performance variation on organizational features of care, future research should clarify the extent to which associated performance deficits are modifiable.

Statewide evaluation of measuring physician delivery of self-management support in chronic disease care.

BACKGROUND: Self-management support is an important component of improving chronic care delivery. OBJECTIVE: To validate a new measure of self-management support and to characterize performance, including comparisons across chronic conditions. DESIGN, SETTING, PARTICIPANTS: We incorporated a new question module for self-management support within an existing annual statewide patient survey process in 2007. MEASUREMENTS: The survey identified 80,597 patients with a chronic illness on whom the new measure could be evaluated and compared with patients' experiences on four existing measures (quality of clinical interactions, coordination of care, organizational access, and office staff). We calculated Spearman correlation coefficients for self-management support scores for individual chronic conditions within each medical group. We fit multivariable logistic regression models to identify predictors of more favorable performance on self-management support. RESULTS: Composite scores of patient care experiences, including quality of clinical interactions (89.2), coordination of care (77.6), organizational access (76.3), and office staff (85.8) were higher than for the self-management support composite score (69.9). Self-management support scores were highest for patients with cancer (73.0) and lowest for patients with hypertension (67.5). The minimum sample size required for medical groups to provide a reliable estimate of self-management support was 199. There was no consistent correlation between self-management support scores for individual chronic conditions within medical groups. Increased involvement of additional members of the healthcare team was associated with higher self-management support scores across all chronic conditions. CONCLUSION: Measurement of self-management support is feasible and can identify gaps in care not currently included in standard measures of patient care experiences.

The effect of performance-based financial incentives on improving patient care experiences: a statewide evaluation.

BACKGROUND: Patient experience measures are central to many pay-for-performance (P4P) programs nationally, but the effect of performance-based financial incentives on improving patient care experiences has not been assessed. METHODS: The study uses Clinician & Group CAHPS data from commercially insured adult patients (n = 124,021) who had visits with 1,444 primary care physicians from 25 California medical groups between 2003 and 2006. Medical directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the patient experience improvement activities adopted by groups. Multilevel regression models were used to assess the relationship between performance change on patient care experience measures and medical group characteristics, financial incentives, and performance improvement activities. RESULTS: Over the course of the study period, physicians improved performance on the physician-patient communication (0.62 point annual increase, p < 0.001), care coordination (0.48 point annual increase, p < 0.001), and office staff interaction (0.22 point annual increase, p = 0.02) measures. Physicians with lower baseline performance on patient experience measures experienced larger improvements (p < 0.001). Greater emphasis on clinical quality and patient experience criteria in individual physician incentive formulas was associated with larger improvements on the care coordination (p < 0.01) and office staff interaction (p < 0.01) measures. By contrast, greater emphasis on productivity and efficiency criteria was associated with declines in performance on the physician communication (p < 0.01) and office staff interaction (p < 0.001) composites. CONCLUSIONS: In the context of statewide measurement, reporting, and performance-based financial incentives, patient care experiences significantly improved. In order to promote patient-centered care in pay for performance and public reporting programs, the mechanisms by which program features influence performance improvement should be clarified.

Awareness of pharmaceutical cost-assistance programs among inner-city seniors.

BACKGROUND: Lack of awareness may be a significant barrier to participation by low- and middle-income seniors in pharmaceutical cost-assistance programs. OBJECTIVE: The goal of this study was to determine whether older adults' awareness of 2 major state and federal pharmaceutical cost-assistance programs was associated with the seniors' ability to access and process information about assistance programs. METHODS: Data were gathered from a cross-sectional study of independently living, English- or Spanish-speaking adults aged > or =60 years. Participants were interviewed in 30 community-based settings (19 apartment complexes and 11 senior centers) in New York, New York. The analysis focused on adults aged > or =65 years who lacked Medicaid coverage. Multivariable logistic regression was used to model program awareness as a function of information access (family/social support, attendance at senior or community centers and places of worship, viewing of live health insurance presentations, instrumental activities of daily living, site of medical care, computer use, and having a proxy decision maker for health insurance matters) and information-processing ability (education level, English proficiency, health literacy, and cognitive function). The main outcome measure was awareness of New York's state pharmaceutical assistance program (Elderly Pharmaceutical Insurance Coverage [EPIC]]) and the federal Medicare Part D low-income subsidy program (Extra Help). RESULTS: A total of 269 patients were enrolled (mean [SD] age, 76.9 [7.5] years; 32.0% male; 39.9% white). Awareness of the programs differed widely: 77.3%) knew of EPIC! and 22.3% knew of Extra Help. In multivariable analysis, study participants were more likely to have heard of the EPIC program if they had attended a live presentation about health insurance issues (adjusted odds ratio [AOR], 3.40; 95% CI, 1.20-9.61) and less likely if they received care in a clinic (AOR, 0.45; 95% CI, 0.23-0.92). Awareness of Extra Help in the multivariable models was more likely among study participants who had viewed a live health insurance presentation (AOR, 3.35; 95% CI, 1.55-7.24) and less likely for those with inadequate health literacy (AOR, 0.15; 95% CI, 0.03-0.74). CONCLUSIONS: Viewing of live health insurance presentations and adequate health literacy were associated with greater awareness of important pharmaceutical cost-assistance programs in this study in low-income, elderly individuals. The findings suggest that use of live presentations, in addition to health literacy materials and messages, may be important strategies in promoting knowledge of and enrollment in state and federal pharmaceutical cost-assistance programs for low-income seniors.

Measuring patients' experiences with individual specialist physicians and their practices.

This study assesses the reliability of patient-reported information about care received by individual specialist physicians. A patient questionnaire that included core composites from the Consumer Assessment of Healthcare Providers and Systems Clinician & Group survey was administered to random samples of patients visiting 1315 physicians from 14 specialties in California during 2005-2006 (n = 68 406 respondents). The quality of specialist-patient interaction and organizational access composites achieved adequate physician-level reliability (alpha(MD) = 0.70) with 30 or fewer patients per specialist, but the care coordination and health promotion support composites were generally less reliable. Patients reporting consult-based relationships with specialists reported worse care experiences across measures (P < .001). The results indicate that reliable patient-reported information can be obtained about specialist physicians with patient sample size requirements comparable to primary care physicians. In order to promote equitable performance measurement in specialty care, future research should clarify the contribution of consult-based specialist-patient relationships to performance differences.

Primary care physician visit continuity: a comparison of patient-reported and administratively derived measures.

BACKGROUND: Studies find that primary care physician (PCP) visit continuity is positively associated with care quality. Some of the evidence base, however, relies on patient-reported continuity measures, which may be subject to response bias. OBJECTIVE: To assess the concordance of patient-reported and administratively derived visit continuity measures. DESIGN: Random samples of patients (n = 15,126) visiting 1 of 145 PCPs from a physician organization in Massachusetts were surveyed. Respondents reported their experienced visit continuity over the preceding 6 months. Usual Provider Continuity (UPC), an administratively derived measure, was calculated for each respondent. The concordance of patient reports and UPC was examined. Associations with patient-reported physician-patient interaction quality were assessed for both measures. RESULTS: Patient-reported and administratively derived visit continuity measures were moderately correlated for overall (r = 0.30) and urgent (r = 0.30) measures and modestly correlated for the routine (r = 0.17) measure. Although patient reports and UPC were significantly associated with the physician-patient interaction quality (p < 0.001), the effect size for patient-reports was approximately five times larger than the effect size for UPC. CONCLUSIONS: Studies and quality initiatives seeking to evaluate visit continuity should rely on administratively derived measures whenever possible. Patient-reported measures appear to be subject to biases that can overestimate the relationship between visit continuity and some patient-reported outcomes.

Primary-care clinician perceptions of racial disparities in diabetes care.

BACKGROUND: Primary-care clinicians can play an important role in reducing racial disparities in diabetes care. OBJECTIVE: The objective of the study is to determine the views of primary-care clinicians regarding racial disparities in diabetes care. DESIGN: The design of the study is through a survey of primary-care clinicians (response rate = 86%). PARTICIPANTS: The participants of the study were 115 physicians and 54 nurse practitioners and physician assistants within a multisite group practice in 2007. MEASUREMENTS AND MAIN RESULTS: We identified sociodemographic characteristics of each clinician's diabetic patient panel. We fit multivariable logistic regression models to identify predictors of supporting the collection of data on patients' race and acknowledging the existence of racial disparities among patients personally treated. Among respondents, 79% supported the collection of data on patients' race. Whereas 88% acknowledged the existence of racial disparities in diabetes care within the U.S. health system, only 40% reported their presence among patients personally treated. Clinicians caring for greater than or equal to 50% minority patients were more likely to support collection of patient race data (adjusted odds ratio [OR] 9.0; 95% confidence interval [CI] 1.2-65.0) and report the presence of racial disparities within their patient panel (adjusted OR 12.0; 95% CI 2.5-57.7). Clinicians were more likely to perceive patient factors than physician or health system factors as mediators of racial disparities; however, most supported interventions such as increasing clinician awareness (84%) and cultural competency training (88%). CONCLUSIONS: Most primary-care clinicians support the collection of data on patients' race, but increased awareness about racial disparities at the local level is needed as part of a targeted effort to improve health care for minority patients.

Physician effects on racial and ethnic disparities in patients' experiences of primary care.

BACKGROUND: Few studies have clarified the mechanisms that contribute to racial and ethnic disparities in primary care quality among comparably-insured patients. OBJECTIVE: To examine relative contribution of "between-" and "within-" physician effects on disparities in patients' experiences of primary care. DESIGN: Regression models using physician fixed effects to account for patient clustering were specified to assess "between-" and "within-"physician effects on observed racial and ethnic disparities in patients' experiences of primary care. PARTICIPANTS: The Ambulatory Care Experiences Survey (ACES) was administered to patients visiting 1,588 primary care physicians (PCPs) from 27 California medical groups. The analytic sample included 49,861 patients (31.4 per PCP) who confirmed a PCP visit during the preceding 12 months. MAIN RESULTS: Most racial and ethnic minority groups were significantly clustered within physician practices (p < 0.001). "Between-physician" effects were mostly negative and larger than "within-physician" effects for Latinos, Blacks, and American Indian/Alaskan Natives, indicating that disparities are mainly attributable to patient clustering within physician practices with lower performance on patient experience measures. By contrast, "within-physician" effects accounted for most disparities for Asians and Pacific Islanders, indicating these groups report worse experiences relative to Whites in the same practices. Practices with greater concentration of Blacks, Latinos and Asians had lower performance on patient experience measures (p < 0.05). CONCLUSIONS: Targeting patient experience improvement efforts at low performing practices with high concentrations of racial and ethnic minorities might efficiently reduce disparities. Urgent study is needed to assess the contribution of "within-" and "between-" physician effects to racial and ethnic disparities in the technical quality of primary care.